**3. Discussion and recommendations**

**2.6. Information systems**

population [28].

**2.7. Community perceptions and behaviors**

72 Immunization - Vaccine Adjuvant Delivery System and Strategies

Unreliable reporting, poor monitoring and supervision systems, and limited use of local data for decision-making are other impediments in the performance of EPI. Data collection is paper-based at the facility level, and then from district upwards, it becomes electronic. Therefore, establishing its credibility has been a challenge. Moreover, for quite some time, the EPI data was not reflected in the district health information system (DHIS) [27]. Inaccurate immunization records lead to the loss of billions of rupees every year [15]. There is a dearth of health systems research to better understand the dynamics between EPI and the beneficiary

Low community awareness and misbeliefs that vaccines cause disease, and the doubts about vaccine safety and effectiveness have been reported as important factors, impeding the uptake of immunization, especially in case of polio [29]. Therefore, educating the masses and population segments with low literacy levels, especially the women, is a must for improving the utilization of immunization services [30]. Gender differential in immunization coverage needs innovative gender mainstreaming strategies at the community level such as employing more female vaccinators and community volunteers for outreach to women [31]. Community activists can also encourage people to seek immunization services, and can increase demand through educating various community segments [32]. Communication between immunization workers and the parents of children has been flawed, and a positive engagement has helped with overcoming the resistance to vaccinations [33]. On the other hand, service providers in clinics do not emphasize the importance of immunization [34]. Religious beliefs and lack of knowledge about the benefits of the vaccines still dictate many pockets of this highly diverse and populated country [35]. Targeted community awareness programs, a robust surveillance network, and engagement with the dominant religious entities can help to root out the issue [36, 37]. Better understanding of the religion and soliciting local support for vaccination campaigns may assist in negotiating access in the areas where refusal is an issue [38].

**Issues Demand/supply side** 

3. Belief in and use of local remedies for prevention and treatment Demand and Supply

5. Distance, time and cost of travel to health facility and long waiting time there Demand and Supply 6. Unavailability of vaccines and vaccinators and dissatisfaction with quality of service Demand and Supply

1. Low awareness level among caregivers and healthcare providers regarding vaccine-

4. Low knowledge and awareness of health care workers regarding VPDs and their

**Table 1.** Demand and supply side barriers in effective implementation of EPI.

2. Concerns of caregivers about safety of Oral Polio Vaccine Demand

7. Missing vaccination card in the home Demand

preventable diseases and their risks

prevention

**barriers**

Demand

Supply

There are several factors which we can bank upon for improving the EPI immunization program in Pakistan: provincial autonomy as called for in the 18th constitutional amendment, re-enactment of a national ministry of health for coordination, the infrastructure needed for the polio program and the renewed focus of the government and the development partners on routine immunization. No program, however, can improve without looking at it insightfully and searching for the underlying factors that may be the reason for its sub-optimal performance. This monograph has unraveled some important areas that need further exploration. These areas along with key recommendations are summarized here for future research and to broaden the evidence base for the immunization program in Pakistan and elsewhere.


recruitment of new vaccinators and women volunteers at the community level. This may help to reduce workload on the existing staff, and perhaps task shift to some extent. Strategies for capacity building may encompass short courses on public health epidemiology, different operational aspects in immunization for the mid-level managers, vaccinators and supervisors. All newly recruited vaccinators must undergo intensive 3 months practical training before being authorized to administer EPI injections independently. This is equally important for the Lady Health Workers who assist the EPI in national immunization days. In addition to this, refresher trainings must be arranged at least once every 2 years. The EPI management staff should undergo management trainings before assuming immunization program responsibilities at any level. This should be followed by a refresher training at least once every 2 years.

supplies/logistics, and action can be taken immediately. Timely and correct interpretation of risk analysis is vital for designing context specific interventions. Community's role in diseases surveillance must also be tapped for early case detection and reporting, initiating

Implementation of the Expanded Program on Immunization (EPI): Understanding the Enablers…

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75

This chapter has endeavored to unravel a multifactorial picture responsible for insufficient immunization coverage in Pakistan. Current evidence suggests that focusing on governance of the program, improving facility-based service delivery and addressing community perceptions could result in the biggest payoffs. Within a multi-cultural milieu and a complex health system, the country presents an ideal case for embarking upon more systematic health systems and implementation research to develop an empirical evidence base and to re-build the routine immunization program to serve the people who are most in need. Moreover, research conducted in the universities must be communicated in simplistic manner to the implementers and policy makers. The current situation pleads the case for generating fresh evidence in order to review policy, programmatic approach, service delivery and stakeholder

an immediate response, and improving outcomes.

**4. Conclusion**

engagement for improving EPI.

**Acknowledgements**

**Conflict of interests**

**List of abbreviations**

EPI Expanded Program on Immunization

UNICEF United Nations Children's Emergency Fund

GAVI Global Alliance for Vaccines & Immunization

WHO World Health Organization

BCG Bacillus Calmette–Guérin

LMIC lower middle income countries

Not applicable.

None.


supplies/logistics, and action can be taken immediately. Timely and correct interpretation of risk analysis is vital for designing context specific interventions. Community's role in diseases surveillance must also be tapped for early case detection and reporting, initiating an immediate response, and improving outcomes.
